Worried sick: Weíve all heard the phrase, but now thereís new evidence that might really knit your brow. New research shows that highly anxious patients with heart disease face nearly double the risk of heart attack or death when compared to those with a more serene outlook on life.
Patients whose anxiety intensified over time were in greatest peril, while those who started out highly anxious but later found inner calm markedly reduced their risk. The research appears in the May 22, 2007 issue of the Journal of the American College of Cardiology (JACC).
"Most patients come in very anxious about their coronary condition," said Charles M. Blatt, M.D., F.A.C.C., director of research at the Lown Cardiovascular Research Foundation and a clinical professor of medicine at Harvard Medical School, both in Boston. "Iím convinced that spending time with the patient and the family and interacting with them as a caring human being is critically important to clinical outcomes."
Previous studies have shown that mental stress and depression have harmful effects on the heart and blood vessels, but until now there has been little information on the corrosive effects of anxiety or the benefits of relieving anxiety over time.
For the study, Dr. Blatt and his colleagues recruited 516 patients with proven coronary artery disease. At the beginning of the study and again each year patients completed a standardized questionnaire about their feelings during the previous week, for example, whether they felt peaceful, felt something bad would happen, took a long time to fall asleep at night, or had upset bowels or stomach.
Patients were followed-up for an average of more than 3 years. During that time, 19 patients died and 44 had a nonfatal heart attack. Cumulative anxiety scores were averaged and adjusted for age, and the patients divided into 3 groups. Those with anxiety scores in the highest third had nearly double the risk of heart attack or death when compared to those with anxiety scores in the lowest third (hazard ratio, 1.97; p=0.04). Looked at from another angle, the data showed a 6 percent increase in the risk of death or heart attack each time the average cumulative anxiety scored notched up by 1 unit (p=0.02).
The initial anxiety score alone offered little clue to the patientís future health. However, an increase in anxiety over time hiked the risk of heart attack or death by 10 percent (p<0.001). Conversely, patients whose anxiety level was in the highest third at baseline, but in the lowest third when cumulative average anxiety levels were tallied, were among the least likely to have a heart attack or to die.
This finding shows not only the need for repeated measurements to accurately gauge the impact of anxiety but also suggests an important role for physicians in reassuring anxious patients, Dr. Blatt said. Spending extra time with patients and families gives the cardiologist an opportunity to talk about heart disease, adjust medications, encourage exercise, and come up with effective strategies to improve cardiac risk factors, such as smoking, high cholesterol and high blood pressure. Equally important, it helps to establish a caring relationship that allays the fears that could shorten a patientís life.
"I tell patients well-managed coronary disease is consistent with a long happy life. If you give people this type of reassurance, it turns a frightening disease into something they can grow old with," Dr. Blatt said.
James L. Januzzi, M.D., F.A.C.C., agreed. "This study provides further insight into the complex connections between the brain and heart," said Dr. Januzzi, an associate professor of medicine at Harvard Medical School and director of the cardiac intensive care unit at Massachusetts General Hospital, Boston. "Appropriately, cardiologists have traditionally focused their therapeutic efforts on factors known to influence long-term outcome in coronary disease, such as making sure to aggressively lower LDL cholesterol. The results of this study demonstrate that we may need to consider more thoroughly evaluating patients with mood disorders such as anxiety, as treatment may very well reduce the risk of heart disease."
Now that research has documented the detrimental effects of anxiety, the next step is to determine the most effective ways of both relieving anxiety and improving cardiac health. Anti-anxiety medications and psychotherapy will be evaluated in the next phase of the study, but Dr. Blatt and his colleagues will also be taking a close look at the doctor-patient relationship. "My hunch is that for the majority of patients, the greatest anxiety-reducing effect comes from having a good relationship with a doctor," Dr Blatt said.
Collaborating in the study were Yinong Young-Xu, Sc.D., M.S., M.A., senior epidemiologist at the Lown Cardiovascular Research Foundation, and Woldecherkos A. Shibeshi, M.D., a clinical and research fellow at Lown Cardiovascular Research Foundation at the time of the study and now a resident in internal medicine at Howard University Hospital, Washington, DC.
Dr. Blatt does not report any potential conflicts of interest regarding this topic.
Also in this issue of JACC
Study suggests heart failure patients with sleep apnea at greater risk of death
Researchers from the Veterans Affairs Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH, evaluated the potentially deadly effects of sleep apnea in patients with heart failure. Sleep apnea is a disorder in which the brain fails to send messages to the respiratory muscles, causing breathing to stop for short periods throughout the night.
The largest of its kind, the study recruited 88 patients with heart failure to spend 2 nights being evaluated in a sleep laboratory. Researchers documented the number of times breathing completely stopped during sleep (apnea) or became shallow for at least 10 seconds (hypopnea). Patients who experienced 5 or more instances of apnea or hypopnea per hour were diagnosed with clinically important sleep apnea.
Over a follow-up that averaged 51 months, patients with central sleep apnea were far more likely to die than those who breathed normally during sleep. The median survival was 45 months in patients with central sleep apnea, as compared to 90 months in those without a sleep disorder. When multiple patient characteristics were taken into account, only 3 were independently linked to an increased risk of death: central sleep apnea, a poorly functioning right ventricle, and a low blood pressure during relaxation of the heart.
"The results of this study are particularly important because previous studies of survival in patients with heart failure, including those considering the role of angiotensin-converting enzyme inhibitors or beta blockers, have not routinely included sleep studies; therefore, the impact of sleep apnea on survival was not known," the authors noted.
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